Presentation is loading. Please wait.

Presentation is loading. Please wait.

Management of the Patient Presenting with Wide Complex Tachycardia

Similar presentations

Presentation on theme: "Management of the Patient Presenting with Wide Complex Tachycardia"— Presentation transcript:

1 Management of the Patient Presenting with Wide Complex Tachycardia
Samir Saba, MD Director, Cardiac Electrophysiology

2 Definition Heart rate > 100 b/min QRS > 120 ms

3 Differential Diagnosis
Supraventricular tachycardia with aberrancy Pre-excited tachycardia Motion artifact Paced rhythm Ventricular tachycardia Idiopathic Non-idiopathic

4 Importance of diagnosing VT
Sensitivity versus Specificity In all patients with WCT, VT is the diagnosis in 80% of cases

5 SVT with aberrancy Typical RBBB Typical LBBB

6 Typical bundle morphology



9 Pre-excited Tachycardia
Manifest versus concealed AP

10 WPW

11 WPW

12 Antidromic AVRT

13 Atrial Flutter with Preexcitation

14 AF with Preexcitation

15 Motion artifact Failure to recognize artifact is common:
94% of internists 58% of cardiologists 38% of EP

16 Motion Artifact Recognize artifact by:
Marching the high frequency signal across the WCT Looking at other available leads

17 Paced ECG

18 Paced ECG Paced Not Paced

19 Ventricular Tachycardia
Idiopathic RVOT VT LVOT VT Lt fascicular VT Non-idiopathic ICM NICM HCM Channelopathy (LQTS, Brugada, etc…)



22 Left fascicular VT

23 Other Classifications for VT
Morphology: Monomorphic Polymorphic Bidirectional Mechanisms: Reentry Automaticity Triggered activity Drug susceptibility: Verapamil sensitive Adenosine sensitive

24 Repetitive VT


26 Non-idiopathic VT

27 Ventricular Tachycardia

28 Bidirectional VT

29 Mechanisms of VT

30 Approach to Management
History Physical Exam ECG EP Study

31 History Age (if >35 yrs, VT>85%)
Symptoms (palpitations, syncope, LH, diaphoresis, angina, seizures, CA…) Circumstances: N/V/D (electrolytes) PMH: Cardiac disease, MI, CHF, ICD, RF Family history: SCD, arrhythmias Medications: QT prolongation, digoxin, diuretics, etc… Habits: Drugs

32 Physical Examination Hemodynamic Stability Signs of acute CHF
Sternal wound PVD Stroke PM/ICD Evidence of AV dissociation (cannon A waves, marked fluctuations in BP, variable S1 intensity) Maneuvers: CSM, pharmacologic interventions (lidocaine, adenosine, BB, verapamil)

33 Other tests Laboratory tests: K, Mg, plasma concentrations of drugs (dig, procan, etc…) CXR: cardiomegaly Echo: structural abnormalities

34 ECG In NSR: AV dissociation Ischemia Fusion beats Acute MI
During WCT: AV dissociation Fusion beats Capture beats Morphology Width of QRS Morphology of the bundles Electrical axis Precordial concordance In NSR: Ischemia Acute MI Old MI Long QT Brugada pattern LVH Epsilon waves

35 AV dissociation

36 Fusion beat

37 ECG

38 ECG

39 Therapy Acute Management: For the Unstable patient:
Emergent synchronized cardioversion If QRS and T cannot be distinguished then defibrillation Cautious use of sedatives and analgesics For the Stable patient: Class I or III AAD Treatment of associated conditions (ischemia, electrolytes,…) Elective cardioversion Interrogation of ICD or PM if present

40 Therapy Chronic Management: AAD: EPS+/-RFA ICD
class IC or III, if structurally normal hearts class III, if structurally abnormal hearts (with ICD) EPS+/-RFA Stand alone therapy in idiopathic VT Adjunctive therapy (+/-AAD) in ischemic VT ICD For primary and secondary prevention of SCD

41 Indication for EPS

42 EP Study Induce the arrhythmia Activation or Pace mapping Ablation

43 Activation Map for VT

44 RVOT VT: pace map

45 Special Case: NSVT EF≤35%, then ICD EF>40%, no ICD
35%<EF≤40%, then EPS and ICD if EPS+ (MUSTT trial) In all these cases, -blockers and other AAD can be used if NSVT is symptomatic.

46 Summary DDX of WCT includes VT, SVT with aberrancy, preexcited tachycardia, artifact, and paced rhythm. VT accounts for 80% Diagnosis hinges of good history, PE, ECG Acute management depends on stability of patient. In the unstable patient, immediate cardioversion or defibrillation is recommended Long term management armamentarium includes: AAD, Ablation, ICD

47 Holter Monitor in a Mouse

48 EPS in a Mouse

49 Question?…

Download ppt "Management of the Patient Presenting with Wide Complex Tachycardia"

Similar presentations

Ads by Google